CMS Revises PMD Coverage Criteria As Industry Prepares for Nov. 15

Nov 01, 2006

Just two weeks before the Nov. 15, 2006, implementation date for new power mobility device (PMD) coverage policies and fee schedules, the Centers for Medicare & Medicaid Services (CMS) revised the local coverage determination (LCD) on Nov. 1.

The most significant change seems to be the removal of the controversial "stand and pivot to transfer" language that could have automatically relegated some highly involved beneficiaries to Group 2 power chairs based solely on the beneficiary's ability to transfer.

An earlier version of the LCD required beneficiaries requesting Group 3 power chairs to be "unable to independently stand and pivot to transfer due to a neurological condition or myopathy." That wording was itself a revision of an earlier LCD's language, which required such beneficiaries to be "unable to stand and pivot to transfer..."

Numerous rehab professionals and beneficiary advocacy groups had protested the initially revised wording. In a statement, the National Coalition for Assistive & Rehab Technology (NCART) said, "This arbitrary (stand and pivot to transfer) test will prevent many Medicare beneficiaries with disabilities from receiving an appropriate mobility device. Certain disabled beneficiaries can perform an independent stand pivot transfer, but still require the durability and functionality of a Group 3 power mobility device to perform the activities of daily living... NCART does not believe that the manner in which an individual transfers to their wheelchair is a valid indicator of the type of mobility device they require."

The new Nov. 1 LCD entirely omits the stand-and-pivot-to-transfer reference, with the new criterion now reading as follows: "The patient's mobility limitation is due to a neurological condition, myopathy or congenital skeletal deformity."

Rehab professionals had also been concerned about beneficiaries with progressive conditions, such as multiple sclerosis or ALS, being potentially unable to receive medically necessary equipment as those conditions progressed.

Commenting on this problem, NCART said, "Individuals whose disease progression is highly predicable, as determined by the physician and clinician, should have access to a device that will fully meet their needs as their condition changes." NCART had suggested that such beneficiaries could have their particular cases individually considered via the appeals process or an Advanced Determination of Medicare Coverage (ADMC), but pointed out, "Unfortunately, only limited configurations of power mobility are eligible for ADMC... NCART recommends that CMS expand the ADMC eligibility criteria to include all HCPCS codes for power mobility devices within Group 3 and Group 4. This is one way of taking into consideration disease progression and those diagnoses that are not neurological or myophathic in nature."

The revised LCD released last week makes single power option or multiple power options wheelchairs in Groups 2, 3, 4 and 5 "eligible for ADMC regardless or whether a power seating system will be provided at the time of initial issue," said a Nov. 1 statement from the Region A/B DME PSC Bulletin. "This will permit advance determination for a patient with a progressive neurological disease, such as amyotrophic lateral sclerosis or multiple sclerosis, who does not yet need a power seating system, but the documentation from the face-to-face examination supports the need for such a system in the near future."

Asked whether the latest LCD revisions were improvements, Invacare Corp.'s VP of Government Relations Cara Bachenheimer said, "Absolutely. (Eliminating the stand-and-pivot-to-transfer requirement) makes the Group 3 coverage criteria infinitely more consistent with how it should be. There are still some minor issues, but between the stand and pivot language and adding the congenital deformity language and the ADMC, it's a huge step forward, a huge improvement and addresses the majority of issues that clinicians have had with the coverage criteria so they're based really
on a more pragmatic and clinical series of criteria."

"We're very pleased with the changes that CMS made," said Seth Johnson, Pride Mobility Products' VP of government affairs. "We have been meeting over the past month or so, since the initial LCD came out, alerting the Medicare carriers along with CMS about the areas that (needed to be) further clarified or corrected in this policy in order to ensure Medicare beneficiaries access to the most medically appropriate equipment."

Asked if the revisions were basically what he had asked for, Johnson said, "Largely, yes. The language eliminating stand-and-pivot-to-transfer clearly does address that problem. However, the language regarding the expansion of advanced determination of Medicare coverage ? that helps provide some additional opportunities for physicians to prescribe technology that will grow with the patient as their disease progresses ? is not the perfect solution to allow physicians the ability to do that. There is an amount of time that it takes for the supplier to get a response from the Medicare program, typically around 30 days, so that's going to potentially delay the delivery of these types of products. So that's the down side to not simply providing physicians up front the ability to prescribe the most medically appropriate equipment."

Specifically regarding the ADMC, Bachenheimer said, "We would prefer for the coverage criteria to include the ability to take into account the future needs of an individual, and the ADMC expansion was as far as (CMS) would go. They relegated that to the ADMC process."

Meanwhile, while the revised LCD seems to be meeting with general industry approval, the industry continues to be deeply concerned by sharply reduced fee schedules due to go into effect on Nov. 15. Asked if she's heard of any activity on that front, Bachenheimer said, "We understand that there is receptivity within CMS, particularly on Group 3 items, that there is some deficiency."

Which ultimately means: Although CMS may be aware that there are serious concerns with the fee schedules ? that much was openly acknowledged in Nov. 8's Open Door Forum ? for now at least, the mobility and rehab industries are still anticipating a Nov. 15 implementation date.